Urinalysis and Body Fluids CRg

Unit 4

Synovial Fluid

Synovial Fluid

• Composition and formation

• Secreted by cells of synovial membrane
• Very viscous, clear ultrafiltrate of plasma
• Contains
• Hyaluronic acid
• Mucopolysaccharides
• Limited amount of plasma protein
• Glucose & uric acid levels equivalent to plasma

Synovial Fluid

• Functions
• – supplies nutrients
• - lubrication of joint

• Reasons for analysis

• Infection
• Hemorrhage
• Degenerative disorders (arthritis)
• Inflammatory disease (SLE)
Synovial Fluid
• Collection
• Arthrocentesis

Synovial Fluid

• Collection
• Tubes
• Heparin – chemistries, immunological tests
• Sterile tube – culturing and crystal evaluation
• EDTA – hematology

Laboratory Testing

Macroscopic Microscopic Chemical Other

Volume Cell counts Protein Aerobic
culture
Color & Clarity Differential Glucose Anaerobic
culture
Inclusions Crystals Uric Acid
Viscosity Cytology Lactic Acid
Clotting LDH
Mucin Clot Rheumatoid Factor
 Classification of Synovial Fluid
• Normal
• Non-Inflammatory
• Degenerative joint diseases
• Inflammatory
• Immunologic disorders ( ie lupus, RA, gout crystals, ETC)

• Septic
• Microbial infections
• Hemorrhagic
• Traumatic injury, tumors, hemophilia,
anticoagulant overdose, etc.

Synovial Fluid - Laboratory procedures

• Hematology
• Physical properties
• Color & clarity = light yellow / straw & clear
• Abnormal colors/ clarity as for other fluids *
• Bloody
o Hemarthrosis
o Traumatic tap
• White / opaque with turbidity
o Indicate pus cells or debris

• Xanthrochromia term not used!

Synovial Fluid - Laboratory procedures

• Physical properties
• Viscosity
• Screening – ‘String Test’ drop from pipette
• Evaluates viscosity
• Normal = @ 5+ cm long before breaking
• Rope’s test for mucin clot
• measures degree of hyaluronate polymerization
• Good / normal = tight ropey mass
• Poor = appears friable or fails to form
Synovial Fluid - Laboratory procedures

• Hematology
• Cell counts
• 0 RBCs / uL
• <200 WBC / uL

• Must let hemacytometer sit longer to allow cells to

settle before counting.
• If dilution needed must use saline
If you use diluent with an acid, such as Unopettes, the sample will clot.

Synovial Fluid - Laboratory procedures

• Cell differential - Wright’s stain

• Cells of peripheral circulation
• neutrophils 7%,
• lymphocytes 24%,
• Monocytes 48%, macrophages 10%,
• and synovial lining cells 4%.

Synovial Fluid - Laboratory procedures

• Synovial lining cells

• (look somewhat similar to mesothelial cells)
Synovial Fluid - Laboratory procedures

• LE cells

• Tart cells

Synovial Fluid - Laboratory procedures

• Other cells
• Reiter cells
•
• Malignant cells
• Organisms

Synovial Fluid - Laboratory procedures

• Microscopic exam for crystals

• Use regular and polarized light
• Crystals may be intra-cellular or extra-cellular
• Monosodium urate – gout artheritis
• Calcium pyrophosphate – pseudo gout
• Cholesterol – non specific; chronic inflammatory
• Apatite – calcific artheritis (mineral change in cartilage)
• Corticosteroid – drug injections
Synovial Fluid - Laboratory procedures

• Chemistries
• Total protein NV = 1.07 – 2.13 g/dL
• Increases seen in inflammatory conditions and following
joint hemorrhage .
• Glucose - similar to current blood level
• Decreased in inflammation or sepsis
• Lactate – assist in differentiation of septic
and inflammatory arthritis
• Uric acid – increased in gouty arthritis.
• if gout is suspected, but no crystals, may need
uric acid level.

Synovial Fluid - Laboratory procedures

• Microbiology
• Gram stain, acid fast stain & cultures
• Certain organisms associated with age
groups
• Children - H. influenzae
• Adults 16-50 – Staph., Strep. Pneumoniae,
Strep pyogenes, Neisseria gonorrhea
• Adults > 50 – Staph. aureus

Synovial Fluid - Laboratory procedures

• Serology
• Serum results more reliable, so not often
done for diagnosis of RA or LE

• Autoantibodies
• Complement levels

• QC – no commercial controls available, use

serum controls if appropriate
Synovial fluid classification
Classification of Synovial Fluid by Test Results
Normal Non- Inflammatory Septic Hemorrhagic
inflammatory
Volume < 3.5 (mL) > 3.5 (mL) > 3.5 (mL) > 3.5 (mL) > 3.5 (mL)
Color Straw Straw / yellow Yellow Variable Red
Clarity Clear Clear Cloudy Cloudy Variable
Viscosity High High Low Variable Low
Cell count/uL < 200 200-2,000 2,000-75,000 > 100,000 Same as bld.
% PMNs < 25 % < 25 % > 50 % > 75% Same as bld.
Gram stain / Negative Negative Negative > 50% Pos Negative
culture
Crystals Negative Negative Frequently Negative Negative
Associated Degenerative Immunologic Non- Trauma,
condition joint disease disorders- LE, gonococcal hemophilia,
RA, Gout, or gonoccal Anticoagulant
pseudo gout septic overdose,
arthritis etc.

Review of Key Points

• Synovial fluid analysis
- Plasma ultrafiltrate secreted by synovial membrane
- Hyalurinic acid and mucopolysaccharides make it viscous
- Lubricates and nourishes joints
- Infection, hemorrhage, degenerative & inflammatory diseases are
reasons for analysis
- Collection is by arthrocentesis
- EDTA (hematology), heparinized (chemistries and serology) and
sterile (cultures and crystals) are collected
- Straw yellow , clear and viscous are normal characteristics
- 0 RBC and < 200 WBC/uL are normal
- Cell counts requiring dilution must be made with saline.
- Any peripheral circulating cell can be seen as well as synovial lining
cells in normal patients.
- Abnormals are classified as non-inflammatory, inflammatory, septic
or hemorrhagic

Synovial Fluid - Laboratory procedures

• 1989 CAP CM 23 Synovial fluid, segs, & macrophages
 Synovial Fluid - Laboratory procedures
• Lupus erythematosus (LE) cells
• Just below center of field
• Neutrophil has engulfed a homogenous nuclear mass.
• ASCP 130 synovial fluid with LE cell

Synovial Fluid - Laboratory procedures

• Lupus erythematosus cell – far right side @ 3 o’clock

Synovial Fluid - Laboratory procedures

• 1993 CAP CM 21 synovial fluid. Segs and leukophage
 Synovial Fluid - Laboratory procedures
• 1993 CAP CM 20 synovial fluid. Monosodium urate crystals

Microscopic Analysis: Crystals-Uric Acid

Synovial fluid with acute inflammation

Synovial fluid with acute
inflammation and monosodium urate
crystals. (Wright–Giemsa stain and
polarized light).
and monosodium urate crystals. The
needle-shaped crystals demonstrate
negative birefringence, because they
are yellow when aligned with the
compensator filter and blue when
perpendicular to the filter (Wright–
Giemsa stain and
polarized/compensated light).

Synovial Fluid - Laboratory procedures

• Left – needle shaped monosodium urate crystals seen in a patient
with gouty arthritis
• Right 1987 CAP CM 18B synovial fluid. Monosodium urate crystals
 Synovial Fluid - Laboratory procedures
• 1989 CAP CM 24 synovial fluid. Calcium pyrophosphate - polarized

Microscopic Analysis: Crystals-other

Synovial fluid with acute inflammation
and calcium pyrophosphate dihydrate
crystals (Wright–Giemsa stain and
polarized light).
Synovial fluid with acute inflammation
and calcium pyrophosphate dihydrate
crystals. The rhomboidal intracellular
crystal (center) demonstrates positive
birefringence, because it is blue when
aligned with the compensator filter
(Wright–Giemsa stain and
polarized/compensated light).